Promoting Healthy Coping & Addressing Negative

Emotion in Diabetes Management

Capstone Meeting Tucson, Arizona

October 18 – 20, 2006

Anonymous, Northwest PCP:

“You know, when I have a patient who has been depressed and becomes diabetic, I breathe a sigh of relief.

“When they are depressed, all I have is medication and ‘good luck,’ but when they become diabetic, they become eligible for a structure of integrated treatment, self management, and support.”

Overview of Presentation Approaches to depression in Diabetes Initiative

Rethinking the issues Relationships between depression and diabetes management

Scope of negative emotion Approaches to other negative emotions Healthy Coping

Integrating Healthy Coping and addressing negative emotions in diabetes self management

Among those with Diabetes, Depression Associated with:

Poor Glycemic Control (Gross et al. J Gen Intern Med. 2005 20(5): 460­466).

Mortality • Minor depression associated with a 1.67­fold increase in

mortality; major depression with 2.30­fold increase (Katon et al. Diabetes Care 2005 28(11): 2668­2672 )

• Greater mortality, macro­ and microvascular complications, disability in activities of daily living (Black et al. Diabetes Care 26:2822–2828, 2003)

Two­Way Street (Lustman et al. J Diab Complications. 2005 19(2):113­122): • Depression associated with poor metabolic control, poor

adherence, and increased in health care expenditures • Poor metabolic control may exacerbate depression and diminish

response to antidepressant regimens Costs • 50­75% increases in health service costs; proportionally similar to

that in general population but absolute dollar difference much greater (Simons et al. Gen Hosp Psychiatry 2005 27(5): 344­351)

Health Care Costs in Primary Care Patients with Diabetes

Adjusted for age, gender, medical comorbidity, diabetes severity, and diabetes knowledge, *p<.05

Ciechanowski et al., 2000

+51% Primary care

+73% Ambulatory

+88% Total

High Depression/ Low Depression

Cost category

Care for Depression in Diabetes Management

• Nine sites cooperated in depression work group

• Recognized how depression interferes with promoting self management

• Identified PHQ­9 as preferred screening instrument – PHQ­9 > 10 (Moderate or worse) in 30% to 70%

• Shared experience in developing systematic approaches to those with depression

Approaches to Depression

• Improved Delivery System Design • Integrating Mental Health Services • Incorporating Cultural Traditions into Treatment

• Mind­body focus

Improved Delivery System Design

• Identification and referral of depressed patients to PCPs

• Provide PCPs with enhanced mental health support

• Providence­St. Peter: – MAs screen all diabetic patients with PHQ9 – Decisions re: Rx left to patient­provider encounter – Onsite psychiatrist available for consultation to PCPs

Integrating Mental Health Services

• On­site mental health services • Direct, often same­day referral from PCP to counselor

• Psychosocial interventions: – Individual counseling sessions – Group therapy sessions

• Enhance communication between PCPs and counselors by including mental health notes in primary care chart.

• All 9 provide both medical and psychosocial interventions

Examples of Integrating Mental Health Services Community Health Center & La Clinica de la Raza

• Screening – Staff screen with PHQ­9, refer to psychologist (CHC) – Nutritionist or PCP screens and refers to Viviendo Bien (LCdlR)

• Treatments Provided – Solution Focused Brief Therapy and Group Therapy (CHC)

– Viviendo Bien – Group therapy for depression and diabetes focused on coping strategies, adherence to anti­ depressants, group sharing, mind­body health (LCdlR)

• Coordination – Psychologist and counselor chart in medical records along with PCP (CHC and LCdlR)

Example of Integration: Promotoras in Gateway Health Center and Campesinos Sin Fronteras • Screening and Referral

– Promotoras teach self management classes and screen participants with PHQ­9 (Gateway and Campesinos)

– Refer to PCPs in Center (Gateway) or providers in community (Campesinos)

• Ongoing Follow Up and Support – Campesinos:

• Family Curriculum to build rapport with family members • 11 Module Curriculum for follow­up and support – self esteem, coping skills, other mental health topics

• Presentations from psychology society – Gateway Depression Protocol:

• weekly phone contact emphasizing mood improvement • trouble­shooting use of antidepressant medications • suicide prevention • social and emotional support

Example of Incorporating Cultural Traditions Minneapolis American Indian Center & Native American Community Clinic

3 Components for Depression: Full Circle Diabetes Program 1. In Clinic

– All patients with diabetes screened – Medication treatment from PCP and/or counseling with on­ site Native American counselor

– Counselor incorporates Native American beliefs and traditions into counseling

2. Talking Circle Support Group bi­monthly at Indian Center – Facilitated by council member and based on Native American traditions

3. Clinic supports patients' decisions to consult traditional healers, considered important, culturally relevant resource for depression

Mind­Body Focus

• Interrelationship between physical and psychological symptoms.

• Relaxation training • Yoga classes • Discussions about the relationships of physical and psychological symptoms

• Full Circle Diabetes Program emphasizes physical, mental, emotional and spiritual

Evolution in Understanding Depression in Diabetes Management

Three­Stage Development 1. Have to treat depression before can make progress with self management

2. Addressing depression is part of self management

3. Not just depression, but full range of negative emotionality, from normal to clinical

Normalize attention to negative emotionality

Negative Emotion in Health

Disease and/or death more likely among •Anxious •Angry and hostile •Depressed • Stressed • Socially isolated

Daily Stressors, Hassles

Normal Distress, e.g., following Diagnosis of Diabetes

Enduring Personal Styles, e.g.,

“High Maintenance”

Diagnosable Problem, e.g., Depression,

Anxiety Disorder

Problems that are Hard to

Treat

Dimension of Negative Emotion

Skills for Relationship & Emotional Management

• Problem solving skills • Communication skills

– Relationship skills – Assertive skills or “self representation” – Social skills

• Stress management – Relaxation, meditation, yoga, etc.

• Cognitive skills for combating stressful interpretations of events

• Productive engagement

Healthy Coping

Daily Stressors, Hassles

Normal Distress, e.g.,

to Dx

Enduring Personal

Styles, e.g., High

Maintenance

Diagnosable Problem, e.g., Depression, Anxiety Disorder

Refractory Pathology

Relaxation skills, yoga, meditation

Social Skills, Assertion, Relationship Skills

Cognitive Management

Problem Solving

Programmatic Approaches: • Healthy Coping as routine part of diabetes education and

self management classes • Medication through primary care • Opportunity to discuss negative emotions routine part of

regular care – with PCP, RN, CHW, etc. • Support groups – diabetes is “for the rest of your life” • Counseling for negative emotions and to improve Healthy

Coping • Tools for individuals to use on their own in improving

coping skills (Marshall University) • Promotoras/CHWs provide support and are trained to

encourage problem solving, teach stress management skills, and refer those in need of specialized care

• Referral care – psychotherapy, medication

Survey of Grantees, Fall, 2005

92% Problem solving/ critical thinking skills (e.g., identify the problem, generate alternative solutions….)

58% Other coping strategies

67% Communication skills: e.g., active listening, assertiveness/“I” messages, social skills training

67% Cognitive techniques: e.g., positive self­talk, guided imagery, visualization, mindfulness, meditation

92% Mind/body techniques: e.g., better breathing, muscle relaxation, yoga

"Yes" Healthy Coping Interventions Employed

12 Respondents

Breadth of Treatment

of Negative Emotion

Daily Stressors, Hassles

Normal Distress, e.g.,

to Dx

Enduring Personal

Styles, e.g., High

Maintenance

Diagnosable Problem, e.g., Depression, Anxiety Disorder

Refractory Pathology

Specialty care – psychology, psychiatry

Counseling by general staff, Educational group

Support Groups, Self Management Groups

Community Health Workers

Self Management Classes & Healthy Coping • Shared emphasis on problem solving

– Identify specific goal – Set action plan – Follow up, review and revise, support

• Shared skills – Relaxation, also yoga, mind­body approaches – Cognitive re­evaluation (e.g., not making mountains out of mole hills)

– Self­representation/assertion – Relationship enhancement

• Support from group, leader, Promotoras

Integration of Self Management and Healthy Coping

• Common procedures and principles • Problem Solving interventions from behavior therapy and behavioral medicine on which self management of chronic disease is based

• Cognitive behavioral and problem solving therapies for depression

• Thus, interventions to promote self management in diabetes might also mitigate the impact of depressive symptoms, even serving as an effective behavioral treatment for depression.

Anonymous, Northwest PCP:

“You know, when I have a patient who has been depressed and becomes diabetic, I breathe a sigh of relief.

“When they are depressed, all I have is medication and ‘good luck,’ but when they become diabetic, they become eligible for a structure of integrated treatment, self management, and support.”

Resources & Support for Self Management

• Individualized assessment, including consideration of individual’s perspectives, cultural factors

• Collaborative goal setting • Building skills • Follow­up and support • Community Resources (and Policies) • Continuity of quality clinical care

Applies to Depression as Much as Diabetes

Wide Range of Approaches to Wide Range of Problems

• Wide range of personal, family, and social influences on depression, negative emotion, and coping among those with diabetes

• Wide range of problems: depression, anger, anxiety, social isolation à Healthy Coping

• Wide range of populations and settings • Calls for wide range of approaches

Wide Range of Care Feasible in Under­ Resourced Settings

• In spite of limited resources, each of nine sites in depression work group provides some variety of psychotherapy, group therapy, or counseling to its patients in addition to medication for depression

• The resourcefulness of real­world, under­ resourced, primary care sites in arranging choices among treatment for depressed patients is striking

Promoting Healthy Coping & Addressing Negative

Emotion in Diabetes Management

Capstone Meeting Tucson, Arizona

October 18 – 20, 2006

Health Care Outcomes Continuum

Immediate Outcomes

Learning Knowledge

Skill Acquisition Behavior Change

Intermediate Outcomes

Improved Clinical Indicators

Post­Intermediate Outcomes

Improved Health Status

Long Term Outcomes

Mulcahy K. et al. Diabetes Self­management Education Core Outcomes Measures: Technical Review. The Diabetes Educator 29(5) September/October 2003

Healthy eating Being active Monitoring Taking medications Problem solving Reducing risks Healthy coping

TM

Promoting Healthy Coping & Addressing Negative

Emotion in Diabetes Management

Capstone Meeting Tucson, Arizona

October 18 – 20, 2006